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Cogan JC, McFarland MM, May JE, Lim MY. Quality improvement approaches to heparin-induced thrombocytopenia: a scoping review. Res Pract Thromb Haemost 2023; 7:102219. [PMID: 38077807 PMCID: PMC10704520 DOI: 10.1016/j.rpth.2023.102219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 02/12/2024] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a relatively uncommon condition characterized by 2 exceedingly common phenomena in hospitalized patients: thrombocytopenia and heparin exposure. Consequently, HIT is frequently overdiagnosed and inappropriately treated. These issues are the focus of many quality improvement (QI) initiatives. Objectives In this scoping review, we identified and characterized all published QI studies on improving the diagnosis and management of HIT. Methods We conducted a systematic literature search through April 2022 for studies reporting on QI interventions regarding the diagnosis, treatment, and/or prevention of HIT. Results Thirty studies were included in the final review. Studies were separated into 5 groups based on the focus of the interventions: increasing HIT recognition, reducing HIT incidence, reducing HIT overdiagnosis, promoting safer HIT management, and creating HIT task forces. Nine studies focused on the implementation of 4Ts score calculator into electronic medical record orders for HIT testing, while only 1 evaluated the impact of reducing unfractionated heparin use in favor of low-molecular-weight heparin. Six studies focused on the implementation of direct thrombin inhibitor management protocols, while none evaluated the use of alternative anticoagulants in HIT management. Conclusion The bulk of published HIT QI research focused on reducing overdiagnosis and promoting safer direct thrombin inhibitor therapy, while minimal attention has been devoted to HIT prevention and the use of evidence-based alternative HIT therapies.
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Affiliation(s)
- Jacob C. Cogan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mary M. McFarland
- Spencer S. Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
| | - Jori E. May
- University of Alabama at Birmingham Medicine Birmingham, Alabama, USA
| | - Ming Y. Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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Applications of Artificial Intelligence in Thrombocytopenia. Diagnostics (Basel) 2023; 13:diagnostics13061060. [PMID: 36980370 PMCID: PMC10047875 DOI: 10.3390/diagnostics13061060] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/26/2023] [Accepted: 03/04/2023] [Indexed: 03/15/2023] Open
Abstract
Thrombocytopenia is a medical condition where blood platelet count drops very low. This drop in platelet count can be attributed to many causes including medication, sepsis, viral infections, and autoimmunity. Clinically, the presence of thrombocytopenia might be very dangerous and is associated with poor outcomes of patients due to excessive bleeding if not addressed quickly enough. Hence, early detection and evaluation of thrombocytopenia is essential for rapid and appropriate intervention for these patients. Since artificial intelligence is able to combine and evaluate many linear and nonlinear variables simultaneously, it has shown great potential in its application in the early diagnosis, assessing the prognosis and predicting the distribution of patients with thrombocytopenia. In this review, we conducted a search across four databases and identified a total of 13 original articles that looked at the use of many machine learning algorithms in the diagnosis, prognosis, and distribution of various types of thrombocytopenia. We summarized the methods and findings of each article in this review. The included studies showed that artificial intelligence can potentially enhance the clinical approaches used in the diagnosis, prognosis, and treatment of thrombocytopenia.
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Nilius H, Cuker A, Haug S, Nakas C, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Kashev A, Sznitman R, Bakchoul T, Nagler M. A machine-learning model for reducing misdiagnosis in heparin-induced thrombocytopenia: A prospective, multicenter, observational study. EClinicalMedicine 2023; 55:101745. [PMID: 36457646 PMCID: PMC9706528 DOI: 10.1016/j.eclinm.2022.101745] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diagnosing heparin-induced thrombocytopenia (HIT) at the bedside remains challenging, exposing a significant number of patients at risk of delayed diagnosis or overtreatment. We hypothesized that machine-learning algorithms could be utilized to develop a more accurate and user-friendly diagnostic tool that integrates diverse clinical and laboratory information and accounts for complex interactions. METHODS We conducted a prospective cohort study including 1393 patients with suspected HIT between 2018 and 2021 from 10 study centers. Detailed clinical information and laboratory data were collected, and various immunoassays were conducted. The washed platelet heparin-induced platelet activation assay (HIPA) served as the reference standard. FINDINGS HIPA diagnosed HIT in 119 patients (prevalence 8.5%). The feature selection process in the training dataset (75% of patients) yielded the following predictor variables: (1) immunoassay test result, (2) platelet nadir, (3) unfractionated heparin use, (4) CRP, (5) timing of thrombocytopenia, and (6) other causes of thrombocytopenia. The best performing models were a support vector machine in case of the chemiluminescent immunoassay (CLIA) and the ELISA, as well as a gradient boosting machine in particle-gel immunoassay (PaGIA). In the validation dataset (25% of patients), the AUROC of all models was 0.99 (95% CI: 0.97, 1.00). Compared to the currently recommended diagnostic algorithm (4Ts score, immunoassay), the numbers of false-negative patients were reduced from 12 to 6 (-50.0%; ELISA), 9 to 3 (-66.7%, PaGIA) and 14 to 5 (-64.3%; CLIA). The numbers of false-positive individuals were reduced from 87 to 61 (-29.8%; ELISA), 200 to 63 (-68.5%; PaGIA) and increased from 50 to 63 (+29.0%) for the CLIA. INTERPRETATION Our user-friendly machine-learning algorithm for the diagnosis of HIT (https://toradi-hit.org) was substantially more accurate than the currently recommended diagnostic algorithm. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies shall validate this model in wider settings. FUNDING Swiss National Science Foundation (SNSF), and International Society on Thrombosis and Haemostasis (ISTH).
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sigve Haug
- Mathematical Institute, University of Bern, Bern, Switzerland
- Albert Einstein Center for Fundamental Physics and Laboratory for High Energy Physics, University of Bern, Bern, Switzerland
| | - Christos Nakas
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Volos, Greece
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, United States
| | - Lukas Graf
- Cantonal Hospital of St Gallen, Switzerland
| | | | - Raphael Sznitman
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Corresponding author. Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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4
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Bolliger D, Santer D, Tanaka KA. Heparin-Induced Thrombocytopenia in Patients with Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2022; 36:1880-1882. [DOI: 10.1053/j.jvca.2022.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/11/2022]
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5
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Pishko AM. Heparin-induced thrombocytopenia and cardiovascular surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:536-544. [PMID: 34889428 PMCID: PMC8791147 DOI: 10.1182/hematology.2021000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Clinicians generally counsel patients with a history of heparin-induced thrombocytopenia (HIT) to avoid heparin products lifelong. Although there are now many alternative (nonheparin) anticoagulants available, heparin avoidance remains challenging for cardiac surgery. Heparin is often preferred in the cardiac surgery setting based on the vast experience with the agent, ease of monitoring, and reversibility. To "clear" a patient with a history of HIT for cardiac surgery, hematologists must first confirm the diagnosis of HIT, which can be challenging due to the ubiquity of heparin exposure and frequency of thrombocytopenia in patients in the cardiac intensive care unit. Next, the "phase of HIT" (acute HIT, subacute HIT A/B, or remote HIT) should be established based on platelet count, immunoassay for antibodies to platelet factor 4/heparin complexes, and a functional assay (eg, serotonin release assay). As long as the HIT functional assay remains positive (acute HIT or subacute HIT A), cardiac surgery should be delayed if possible. If surgery cannot be delayed, an alternative anticoagulant (preferably bivalirudin) may be used. Alternatively, heparin may be used with either preoperative/intraoperative plasma exchange or together with a potent antiplatelet agent. The optimal strategy among these options is not known, and the choice depends on institutional experience and availability of alternative anticoagulants. In the later phases of HIT (subacute HIT B or remote HIT), brief intraoperative exposure to heparin followed by an alternative anticoagulant as needed in the postoperative setting is recommended.
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Affiliation(s)
- Allyson M. Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Correspondence Allyson M. Pishko, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3rd Floor Dulles, Philadelphia, PA 19104; e-mail:
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Northam KA, Chen SL, Stivers AP, Cicci JD, Hedrick TL, Rollins-Raval MA, Kasthuri RS. Impact of a multidisciplinary workflow on safety and management of patients with heparin-induced thrombocytopenia. Am J Health Syst Pharm 2020; 78:49-59. [PMID: 33103184 DOI: 10.1093/ajhp/zxaa342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. Management strategies are complex and include discontinuing heparin products, initiating alternative anticoagulants, interpreting laboratory test results, documenting heparin allergies, and providing patient education. Medication error reports and a retrospective review conducted at an academic medical center revealed an opportunity for a quality improvement initiative and led to the creation of a multidisciplinary workflow for the management of HIT. In a pre-post study, the impact of the multidisciplinary workflow on the safety and management of HIT was evaluated. METHODS The preimplementation group consisted of adult patients tested for suspected HIT from April 4, 2014, through May 31, 2016; the postimplementation group consisted of adult patients tested from November 1, 2016, through October 31, 2018. The primary outcome was the incidence of heparin product administration while HIT testing was ongoing. The secondary outcome was the rate of appropriate heparin allergy documentation. RESULTS The incidence of heparin product administration while HIT testing results were pending was significantly reduced, from 54.2% to 20.0% (P < 0.001), after workflow implementation. The rate of appropriate heparin allergy documentation significantly increased, from 95.0% to 100% (P < 0.001). CONCLUSION Implementation of a multidisciplinary workflow for the management of HIT significantly reduced the incidence of heparin administration while testing was ongoing and improved the rate of appropriate heparin allergy documentation.
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Affiliation(s)
- Kalynn A Northam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Andrew P Stivers
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA
| | - Jonathan D Cicci
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Tanner L Hedrick
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | | | - Raj S Kasthuri
- Division of Hematology and Oncology, University of North Carolina, Chapel Hill, NC
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7
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Wang L, Gong T, Brown Z, Randle C, Guan Y, Ye W, Ming W. Ascidian-Inspired Heparin-Mimetic Magnetic Nanoparticles with Potential for Application in Hemodialysis as Recycling Anticoagulants. ACS Biomater Sci Eng 2020; 6:1998-2006. [PMID: 33455351 DOI: 10.1021/acsbiomaterials.9b01865] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the present study, heparin-mimetic magnetic nanoparticles (HMNPs), which might be used as recycling anticoagulants, were synthesized by coating heparin-mimetic sodium alginate (HLSA) on the surface of iron oxide magnetic nanoparticles (MNPs), using 3,4,5-trihydroxyphenylalanine (TOPA) as a biological adhesive. HLSA was successfully immobilized on the MNP surface, as revealed by Fourier transform infrared spectroscopy and thermal gravimetric analysis, and the core (MNP)-shell (TOPA, HLSA) structure was confirmed by transmission electron microscopy observations. In addition, in vitro studies of protein adsorption, blood clotting time, and contact activation confirmed that the blood compatibility of the HMNP was significantly enhanced compared with the bare MNP. The improved hemocompatibility was attributed to the introduction of the multiple heparin-mimetic groups (-SO3Na, -COONa, and -OH). In addition, the HMNP showed outstanding recycle stability and, thus, can be reused if needed. The synthesized HMNP appeared to be a suitable biomaterial to safely replace heparin as an anticoagulant in patients undergoing long-term hemodialysis.
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Affiliation(s)
- Lingren Wang
- Department of Mechanical and Materials Engineering, Huaiyin Institute of Technology, Huaian 223003, China.,Department of Chemistry and Biochemistry, Georgia Southern University, P.O. Box 8064, Statesboro, Georgia 30460, United States
| | - Tao Gong
- Department of Mechanical and Materials Engineering, Huaiyin Institute of Technology, Huaian 223003, China
| | - Zachary Brown
- Department of Chemistry and Biochemistry, Georgia Southern University, P.O. Box 8064, Statesboro, Georgia 30460, United States
| | - Christopher Randle
- Department of Chemistry and Biochemistry, Georgia Southern University, P.O. Box 8064, Statesboro, Georgia 30460, United States
| | - Yingying Guan
- Department of Mechanical and Materials Engineering, Huaiyin Institute of Technology, Huaian 223003, China
| | - Wei Ye
- Department of Mechanical and Materials Engineering, Huaiyin Institute of Technology, Huaian 223003, China
| | - Weihua Ming
- Department of Chemistry and Biochemistry, Georgia Southern University, P.O. Box 8064, Statesboro, Georgia 30460, United States
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8
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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9
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Pishko AM, Lefler DS, Gimotty P, Paydary K, Fardin S, Arepally GM, Crowther M, Rice L, Vega R, Cines DB, Guevara JP, Cuker A. The risk of major bleeding in patients with suspected heparin-induced thrombocytopenia. J Thromb Haemost 2019; 17:1956-1965. [PMID: 31350937 PMCID: PMC6913895 DOI: 10.1111/jth.14587] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/22/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The presence of a hypercoagulable disorder such as heparin-induced thrombocytopenia (HIT) may protect against anticoagulant-associated bleeding. OBJECTIVES To determine the incidence of major bleeding in patients with suspected HIT. METHODS We performed a retrospective analysis of 310 patients suspected of having HIT from the Hospital of the University of Pennsylvania and an affiliated community hospital. We compared the cumulative incidence of major bleeding following suspicion for HIT by ultimate HIT status (HIT+ or HIT-) and exposure to an alternative anticoagulant (Tx+ or Tx-). Secondary outcomes included the incidence of new/progressive thrombosis and 30-day mortality. RESULTS The incidence of major bleeding was high in the HIT+Tx+, HIT- Tx+, and HIT-Tx- groups (35.7%, 44.0%, and 37.3%, respectively). The time to first major bleeding event did not differ between groups (P = .24). Factors associated with increased risk of major bleeding included intensive care unit admission (HR 2.24, 95% CI 1.44-3.47), platelet count < 25 × 109 /L (HR 2.13, 1.10-4.12), and renal dysfunction (HR 1.56, 1.06-2.27); 35.7% of HIT+Tx+, 13.8% HIT-Tx+, and 9.3% of HIT-Tx- patients experienced new or progressive thrombosis. Mortality was similar among the three groups (26.2% HIT+Tx+, 34.5% HIT-Tx+, and 26.7% of HIT-Tx- [P = .34]). CONCLUSIONS Among patients with suspected HIT, major bleeding was common regardless of HIT status. Contrary to our hypothesis, HIT+ patients were not protected from major bleeding. A better understanding of bleeding risk is needed to inform management decisions in patients with suspected HIT.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel S Lefler
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Phyllis Gimotty
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Koosha Paydary
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Sara Fardin
- Department of Radiology, Tufts Medical Center, Boston, Massachusetts
| | - Gowthami M Arepally
- Division of Hematology, Department of Medicine, Duke University, Durham, North Carolina
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Rice
- Hematology Division, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas
| | - Rolando Vega
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas B Cines
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James P Guevara
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Prospective comparison of the HEP score and 4Ts score for the diagnosis of heparin-induced thrombocytopenia. Blood Adv 2019; 2:3155-3162. [PMID: 30463915 DOI: 10.1182/bloodadvances.2018023077] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/23/2018] [Indexed: 12/31/2022] Open
Abstract
The HIT Expert Probability (HEP) score compared favorably with the 4Ts score in a retrospective study. We assessed the diagnostic accuracy of the HEP score compared with the 4Ts score in a prospective cohort of 310 patients with suspected heparin-induced thrombocytopenia (HIT). A member of the clinical team calculated the HEP score and 4Ts score. An independent panel adjudicated HIT status based on a clinical summary as well as the results of HIT laboratory testing. The prevalence of HIT in the study population was 14.7%. At a cutoff of ≥3, the HEP score was 95.3% sensitive (95% confidence interval [CI], 84.2-99.4) and 35.7% specific (95% CI, 29.8-42.0) for HIT. A 4Ts score of ≥4 had a sensitivity of 97.7% (95% CI, 86.2-99.8) and specificity of 32.9% (95% CI, 27.2-39.1). The areas under the receiver operating characteristic (ROC) curves (AUCs) for the HEP score and 4Ts score were similar (0.81 [95% CI, 0.74-0.87] vs 0.76 [95% CI, 0.69-0.83]; P = .12). The HEP score exhibited a significantly higher AUC than the 4Ts score in patients in the intensive care unit (ICU) (0.86 vs 0.79; P = .03). Among trainee scorers, the HEP score performed significantly better than the 4Ts score (AUC, 0.80 vs 0.73; P = .03). Our data suggest that either the 4Ts score or the HEP score may be used in clinical practice. The HEP score may be preferable in ICU patients and among less experienced clinicians.
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11
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Rauova L, Arepally G, Poncz M, Cines DB. Molecular and cellular pathogenesis of heparin-induced thrombocytopenia (HIT). Autoimmun Rev 2018; 17:1046-1052. [PMID: 30103043 DOI: 10.1016/j.autrev.2018.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Lubica Rauova
- Division of Hematology, Department of Pediatrics, Childrens Hospital of Philadelphia, USA; Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, USA
| | - Gowthami Arepally
- Division of Hematology, Department of Medicine, Duke University School of Medicine, USA
| | - Mortimer Poncz
- Division of Hematology, Department of Pediatrics, Childrens Hospital of Philadelphia, USA; Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, USA
| | - Douglas B Cines
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, USA; Department of Medicine, University of Pennsylvania, Perelman School of Medicine, USA.
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12
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Rice L. HITs and misses in 100 years of heparin. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:667-673. [PMID: 29222319 PMCID: PMC6142618 DOI: 10.1182/asheducation-2017.1.667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Heparin was discovered 100 years ago, and the heparin-induced thrombocytopenia syndrome was described 40 years ago. That the most powerful anticoagulant of the last century can also produce the most extreme prothrombotic diathesis is but one of the paradoxes that surround heparin-induced thrombocytopenia. Standard treatment is alternative anticoagulation. Advances continue to be made regarding pathophysiology, prevention, and treatment. Currently, an epidemic of overdiagnosis threatens the well-being of patients, so efforts to educate clinicians on when and how to make this diagnosis are pressing.
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Affiliation(s)
- Lawrence Rice
- Hematology Division, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX
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13
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Pishko AM, Cuker A. Heparin-Induced Thrombocytopenia in Cardiac Surgery Patients. Semin Thromb Hemost 2017; 43:691-698. [PMID: 28597462 DOI: 10.1055/s-0037-1602664] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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